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Transcript of Int J Ayu Pharm Chemijapc.com/volume10-third-issue/MNAPC-V10-I3-17-p-132-139.pdf · CASE STUDY...
Greentree Group Publishers
Received 16/03/19 Accepted 09/04/19 Published 10/05/19
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Jain and Fiaz 2019 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2019 Vol. 10 Issue 3 www.ijapc.com 132 [e ISSN 2350-0204]
Int J Ayu Pharm Chem CASE STUDY www.ijapc.com
e-ISSN 2350-0204
ABSTRACT
Intratonsillar abscess is an infection occurring in both children and adults.It is a rare
complication associated with tonsillitis which is a common pharyngeal infection.In modern
science, treatment includes incision and drainage along with antibiotics and analgesicswhich
cause unnecessary side effects and in chronic stage there is little or no relief and hence surgery
is advised as the only alternative.Moreover, there is recurrence even after surgical
intervention.In Ayurveda, Intratonsillar abscess can be correlated with Gala Vidradhi which
has indication of Bhedana Karma as treatment. In the present case study, a 26 year old female
patient came with complaints of swelling in the left tonsillar region for the last 6 months
following an episode of acute tonsillitis. She was treated with local application of Apamarga
Kshara andGandusha with Darvyadi Kwatha along with oral medications. There was
significant improvement in patient complaints and marked reduction in swelling with no
recurrence of abscess formation.
KEYWORDS
Intratonsillar abscess, Gala Vidradhi, Apamarga Kshara, Pratisarana, Gandusha
Ayurvedic Management of Intratonsillar Abscess: A Case Study
Isha Jain1* and Shamsa Fiaz2
1,2Shalakya Tantra Department, National Institute of Ayurveda, Jaipur, Rajasthan, India
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INTRODUCTION
Tonsillitis is increasing day by day in our
society due to altered life style, unhealthy
practices, exposure to dust and various
pollutants. Tonsillitis is an inflammation of
the tonsils often affecting school going
children but may also affect adults.
However, intratonsillar abscess is a rare
complication associated with tonsillitis1,2
and there is very little scope for its medical
management. In a massive internet search
using pubmed/ medline services we could
find only 24 cases reported in the medical
literature which were predominately found
in children3-5.Therefore, inferences on the
exact incidence are difficult to ascertain.
The current literature does not provide any
new insights on the pathogenesis of
intratonsillar abscess. On review of
previous works basically two mechanisms
prevails for the formation of intratonsillar
abscess1. The first is that inflammation of
the tonsils, especially acute follicular
tonsillitis leads to accumulation of pus
within the tonsillar crypts and thus an
intratonsillar abscess is formed. The
second postulated mechanism is
haematogenous or lymphatic spread. The
reason for intratonsillar abscess being so
rare is due to the fact that the normal rapid
transit of lymphatic flow within the tonsil
which is about 30 minutes prevents the
accumulation of bacteria within the tonsil
and hence prevents intratonsillar abscess
formation. Alteration in this normal
lymphatic transit is therefore thought to
cause intratonsillar abscess. The clinical
features of intratonsillar abscess can
resemble withtonsillitis or peritonsillar
abscess as all the three may present with
sore throat, odynophagia with or without
referred otalgia6. Tonsillitis however is
often bilateral whereas peritonsillar abscess
and intratonsillar abscess are more
commonly unilateral and the patients report
pain to be predominantly single sided.
Additionally patients with tonsillitis do not
have trismus whereas trismus is a common
feature of peritonsillar abscess. To
distinguish peritonsillar abscess and
intratonsillar abscess, the latter may lack
the erythema and proptosis of soft palate,
however as previously stated the two may
also co-exist. Given at times the lack of
clinical clarity the patient may need
imaging to assist in diagnosis. Management
as with most abscesses consists of incision
and drainage and systemic antibiotics and
in last resort to tonsillectomy. A substantial
high cost of surgical approach, high
recurrence rate, resistance to antibiotics
initiates a search for alternate system of
medicine which is effective, safe and cost
effective and this can be achieved through
Ayurveda.
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In Ayurveda, Intratonsillar abscess can be
compared with Gala Vidradhi which is
explained under Kanthagata
roga7.According to Sushruta,Gala
Vidradhi which is an abscess arising in the
tonsillar region and may further increase in
size to envelope the whole throat. It is
associated with ruja(pain arising from the
vitiation of all doshas)8.InAshtang
Hridhyait is stated that this abscess forms
readily and also quickly accelerates
inflammation and suppuration and highly
painful resembling the discharge as puti
puya(mucopurulent discharge)9. Further the
treatment of Galavidradhi which is not in
any Marmasthan, well inflamed and
suppurated involves Bhedana Karma10.
Considering all the above criteria this case
study was done with Ayurveda perspectives
which may open a doorway to find an
alternate and effectivesolution to the
present problem. To meet this challenge,
the present case study was done with
Apamarga Kshara as local application and
Gandusha with Darvyadi Kwatha along
with oral medications.
CASE REPORT
A 26 year old female patient came to
Shalakya OPD of National institute of
Ayurveda, Jaipur with complaints of
swelling in the left tonsillar region for the
last 6 months following an episode of acute
tonsillitis. After taking detailed history the
patient revealed pain in throat and difficulty
in swallowing not only food but even saliva
since 6 months. She had burning sensation
in throat after consumption of any type
food. The clinical examination revealed a
pale yellow swelling in the left tonsil
(figure 1) which was soft, cystic and tender
on palpation. She had a mildly muffled hot
potato voice but no respiratory
compromise.
Fig 1 Before treatment
Her medical history was unremarkable
except previous episodes of tonsillitis. It
would be prudent to note that patient had no
fever,trismus. The differential diagnosis of
tonsillar cyst, tonsillar lith, paraphyrangeal
abscess were made. Reports of routine
hematological tests like hemoglobin, total
leukocyte count, differential count, were
within normal limits.The Erythrocyte
sedimentation rate was raisedto about
23mm.
On examination –
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Otoscopic examination – bilateral
external auditory canal patent and normal;
right tympanic membrane - intact and
normal, left tympanic membrane- intact
with mild congestion.
External nose - normal appearance
Anteriorrhinoscopy-
Nasal mucosa- congested.
Bilateral inferior turbinates
hypertrophy.
Throat examination-
Congestion seen over tonsils, uvula
and pharyngeal wall.
No evidence of palatal or uvular
asymmetry or bulge.
Intratonsillar abscess in left tonsillar
region.
Posterior pharyngeal wall
(oropharynx) showed granules.
Jugulodigastric lymph nodes were
not palpable.
Treatment administered
1. Apamarga Kshara Pratisarana on
tonsillar abscess surface once a week for 2
sittings.
2. Gandushawith Darvyadi
Kwathafor14 days.
3. Oral intake of Darvyadi Kwatha in
the dose of 30 ml twice a day before meals.
4. Kanchnaar Guggulu 250 mg 2
tablet twice a day after meals with
lukewarm water for 14 days.
Procedure of Kshara Pratisarana
First the patient was made to sit
comfortably. After that lignox 10 % was
sprayed into the oral cavity to reduce the
sensitivity of oropharynx and to prevent
gag reflex. Then Apamarga Teekshna
Pratisarneeya Kshara of pH about 13 was
taken on a sterile cotton ball held with a
long artery forceps and applied gently over
the tonsillar abscess to open the pus pocket
and mildly rubbed for 2 minutes or till the
time taken to count hundred Matra Kala11.
After the specified time the colour of
swelling changed to reddish brown(Pakva
Jambuphalvat)12.After thatthe applied
Kshara was neutralized with lemon juice13.
Burning sensation was observed during and
after the Kshara Pratisarana which
subsided by gargling with lemon juice at
that time.After that, gargling with Darvyadi
Kwatha was advised. The same procedure
was repeated after one week.
RESULTS
After two successive sittings ofApamarga
Kshara the pus in tonsillar area was drained
completely as shown in figure 2.
After the treatment all the symptoms like
pain in throat, difficulty in swallowing,
burning sensation in throat after intake of
any food, muffled voice was reduced
substantially. Erythrocyte sedimentation
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Jain and Fiaz 2019 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2019 Vol. 10 Issue 3 www.ijapc.com 136 [e ISSN 2350-0204]
rate was reduced to 10mm.The patient was
advised to take liquid or semisolid food
which is easily digestible.During follow up
period of 1 month, there was no recurrence
in the patientcomplaints and complete relief
was achieved.
Fig 2 After treatment
DISCUSSION
The exact etiology of intratonsillar abscess
is obscure. However in present case it could
be due to inflammation of the tonsils, which
leads to accumulation of pus within the
tonsillar crypts and thus forming an
intratonsillar abscess. Diagnosis was
confirmed from all above clinical features
including unilateral swelling in tonsillar
region associated with pain in throat
without trismus, tonsillar hypertrophy and
palatal or uvular asymmetry or bulge.
AcharyaSushruta defines kshara as a
substance which has Ksharana and
Kshanan properties14. ApamargaKshara
does Chedana (excision), Bhedana
(incision) and Lekhana (scraping) Karma
simultaneously and it is also
TridoshaShamak as it subdues all the three
vitiated doshas15. It is Katu,Tiktain Rasa,
Laghu, Ruksha andTeekshna in Guna due to
which it can perform Bhedana as well as
Lekhana in Gala Vidrahi thus helpful in
intratonsillar abscess. Hence Apamarga
Kshara helped inopening the pus pockets in
intratonsillar abscess because of its
corrosive nature.Simultaneously
gargle(Gandusha) and gulp(pana) of
Darvyadi Kwatha having Tikta
Rasa16which hasDaha Kandu
Prashmanapropertythereby
reducingburning sensation and itching. It
also hasLekhana and Upshoshana property
due to Ruksha Guna present in the Tikta
Rasa which causes absorption of Kleda and
Kapha.Kashaya Rasa17 in Darvyadi
Kwatha is Vranaropana and Sandhanakar.
It promoted Sleshma, Pitta, Rakta
Prashamanaaction. Kashaya Rasa is
Shothahar and Sleshmala Kala Sankochaka
which promotes healing of mucosa. As
KanchnarGuggulu is indicated in Granthi,
Arbuda, Shothaetc.and having Lekhana
property, thereby it helped in reducing
inflammation.
CONCLUSION
Present case study showed that local
application of Apamarga Ksharaand
Gandusha with Darvyadi Kwatha along
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Jain and Fiaz 2019 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2019 Vol. 10 Issue 3 www.ijapc.com 137 [e ISSN 2350-0204]
with oral medications has been found very
effective in this case. Despite the
limitations of this case study in a single
patient, this treatment modality may be an
eye opener for further studies to effectively
manage intratonsillar abscess through
Ayurveda.
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Jain and Fiaz 2019 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2019 Vol. 10 Issue 3 www.ijapc.com 138 [e ISSN 2350-0204]
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Jain and Fiaz 2019 Greentree Group Publishers © IJAPC Int J Ayu Pharm Chem 2019 Vol. 10 Issue 3 www.ijapc.com 139 [e ISSN 2350-0204]
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